The Journal of Sociology & Social WelfareVolume 7Issue 3 May Article 6

May 1980

Veterans' Medical Care: The Politics of anAmerican Government Health ServiceJudith LaskerBucknell University

Follow this and additional works at: https://scholarworks.wmich.edu/jssw

Part of the Health Policy Commons, and the Social Work Commons

This Article is brought to you for free and open access by the Social Work atScholarWorks at WMU. For more information, please contactmaira.bundza@wmich.edu.

Recommended CitationLasker, Judith (1980) "Veterans' Medical Care: The Politics of an American Government Health Service," The Journal of Sociology &Social Welfare: Vol. 7 : Iss. 3 , Article 6.Available at: https://scholarworks.wmich.edu/jssw/vol7/iss3/6

brought to you by COREView metadata, citation and similar papers at core.ac.uk

provided by ScholarWorks at WMU

VETERANS' MEDICAL CARE;THE POLITICS OF AN AMERICAN GOVERNMENT HEALTH SERVICE

1

Judith LaskerBucknell University

The history of veterans' benefits and services in theUnited States is reviewed; it demonstrates their respon-siveness to dominant political, economic, military andmedical interests. The ideological position that socialservices must be "deserved" is also seen to be an importantinfluence on the V.A. system. The consequent inaccessi-bility of V.A. medical care to most veterans and almostall non-veterans raises questions about the appropriatenessof the V.A. system as a model for national health care.

The vast and ever-increasing literature on medical care in theUnited States all but ignores a major component of the nationalmedical system--the medical services and institutions of the VeteransAdministration. Although the V.A. has the "largest medical-caredelivery system in the United States" (National Academy of Sciences,1977: 1), it is rare to find it even mentioned in discussions ofnational health policies. However, when it is mentioned in theliterature, the V.A. is often discussed as a model for a potentialnational health system (Lipsky et al, 1976; Sapolsky, 1977; Chase,1977). Since, despite criticisms of its quality and relevance(National Academy of Sciences, 1977; Starr, 1973), the V.A. islikely to continue to be an important segment of American healthcare in any type of future system, it is essential to examine themodel carefully. This paper reviews available literature, the historyof veterans' medical services, and recently collected utilization datain order to analyze the principles underlying the creation and con-tinued growth of the V.A. medical system. One must examine the forceswhich have influenced this set of institutions if one wants to con-sider the possibilities for a system of national health care in theUnited States.

One can only conclude from the paucity of literature that the V.A.medical system is considered an aberration by most students of Americanhealth care (if it is considered at all)--a federally-run nationalhealth service in a nation presumably dedicated to free enterprise

1. I would like to thank Bucknell University for a grant received tocarry out this research. Thanks also to Gregory Gaertner, AllenImershein, Florence Katz, Arnold Lasker, Miriam Lasker, John Kendrick,Jean Potuchek, Matthew Silberman, Barry Siegel, Martha Verbrugge, AlbertWessen and the V.A. library staff for their helpful comments and

medicine. This paper will present the proposition that the V.A.medical system is not at all an aberration. Rather, I suggest thatit is very similar to other health and social services in the UnitedStates. It consists of a set of resources whose distribution andadministration have been subject to the priorities of dominantinterests in the society. Military, political, economic, andmedical elites have all participated in shaping medical care forveterans. Although their efforts have produced ever-improving andexpanding services for millions of people, their interests in theV.A. system go beyond the goal of caring for veterans' medicalproblems. The other priorities may in fact conflict with or de-tract from the ideal of comprehensive, accessible, and high qualityhealth care. It is these other goals which will be considered inthis paper.

It will be necessary first to discuss this view of socialservices as societal resources allocated to serve goals other thanthose of meeting the needs of clients. Secondly, the history ofveterans' services will be examined as an example of this phenomenon,and the impact of various interests on that history will be analyzed.An additional factor which affects V.A. medicine and is also signif-cant in other social services is the ideological position that somepotential clients are more deserving of services than others. Thespecific characteristics of the hierarchy of eligibility are alsorelated to non-medical priorities. In the last section, the effectthese issues have on the ability of the V.A. to meet the needs ofits client population will be considered. The purpose here is toanalyze the factors which result in the inequitable distribution ofnational social welfare resources. A national health system whichresembles the V.A. would potentially also be subject to these same

inequalities.

I. The Politics of Social Services

A number of authors over the last few years have examinedhealth and social services in the U.S. and have pointed out thatthey serve the economic and political interests of dominant groupsin the society. Foremost among these analysts has been VicenteNavarro (1976, 1977a), who has demonstrated that ownership and/orcontrol of medical services by the upper-class have produced asystem which meets the needs of this small minority more than thoseof the majority of the population. Krause examines the process bywhich health programs are subordinated to the goals of power andprofit and how this is justified by the dominant capitalist ideal-ogy. He asserts that "...health care is simply one type of house-keeping function which a capitalist state needs to keep the wheelsof industry rolling,...no understanding of the health servicesystem is possible without looking outside of it to the widerpolitical economy" (1977: 154).

Studies of medical services in other societies have alsorevealed underlying interests which produce systems often unrespon-sive to the health problems of the population. For instance,Field's (1957) study of medical services in the Soviet Union duringthe Stalinist era of heavy industrialization showed the role ofphysicians in promoting economic growth by limiting the number ofsick days available to workers. An analysis of health care in theIvory Coast reveals the continuous use of medical resources, bothduring colonial rule and after independence, to promote economicgrowth and political stability (Lasker, 1977). An increasingnumber of studies on national health systems support this view-point (Navarro, 1977b).

When the state is directly involved in the planning anddirection of health care services, as it is in most nations otherthan the United States, the impact of these other interests is mostvisible. Yet the same analysis can also be applied in the Americancontext. Waitzkin and Navarro both note that the American govern-ment uses medical resources to reduce popular dissent, to provideprofit for private industry, and to reinforce "dominant frameworksin scientific and clinical medicine that are consistent with thecapitalist economic system" (Waitzkin, 1978: 36).

The state's support of economic and political goals through thedistribution of medical resources is one aspect of its activities inthe broader area of social welfare services. A number of scholarshave pointed out the many ways in which American welfare policiesrespond to the dominant capitalist interests by promoting stability,maintaining a reserve of surplus labor, funding private enterprise(for instance, through housing programs) and reinforcing values ofindividualism (by stigmatizing recipients and eliminating from therolls any who might be considered 'undeserving'). These prioritieshave shaped policy much more than any assessment of the needs ofthe nation's poor. (Piven and Cloward, 1971; Galper, 1975).

The V.A. medical care system offers an important case toillustrate the applicability of this analysis to medical care in theUnited States. It reflects both direct state involvement and theinfluence of the institutions and models of private medicine. It isfunded and administered by the federal government but is closely tiedto medical schools and the prevailing patterns of personnel trainingand hierarchy. Studying the history of the V.A. illuminates the sig-nificance of political, military, economic and organized medicalinterests in determining the characteristics of V.A. medical care.

II. V.A. Medical Care - Historical Overview1

Medical care was first made available to disabled veterans in

the United States with the establishment of the Soldiers' Home, the

Naval Home, and the National Homes for Disabled Volunteer Soldiers

following the Civil War. Except for the men admitted to these few

institutions, no other medical care was provided for veterans until

World War I, when Public Health Service hospitals or private hos-pitals under contract with the Bureau of War Risk Insurance caredfor the war-injured.

By 1920, fifty government hospitals were treating disabledsoldiers and veterans, and Congress allocated funds for the construc-tion of more hospitals. A Veterans' Bureau, created in 1921 toconsolidate insurance and medical functions, took over the adminis-tration of the Public Health Service Hospitals which were servingveterans. In 1930, the Veterans Administration replaced the VeteransBureau and incorporated the National Homes and the Bureau of Pensions.Since 1930, the V.A. system has continued to grow. It now operates172 hospitals, 104 nursing homes and domiciliaries, and 220 outpatientclinics, employs 181,000 people, and has a budget for 1980 of $5.6billion (Wehr, 1979a).

The growth of V.A. medical services has continued both in wartimeand in peacetime, due to a different set of forces at work in eachsituation. During every war in this century, Congress has allocatedincreased funds for the care of the wounded. Each period of mobili-zation produced additional veterans and added to the numbers of thedisabled. As a result, facilities were expanded and new ones builtto accommodate the demand.

The number of disabled patients diminished, however, within afew years after each war, leaving the problem of unused hospital beds.The recent war having strengthened the V.A. structures and contributedto the ranks of veterans' organizations, political pressures werebrought to bear on Congress to loosen eligibility requirements inorder to increase admissions rather than cut back on facilities. Bythe time the next war started, the V.A. hospitals were again close tocapacity, and Congress again allocated funds for additional facilitiesto accommodate the increased number of veterans and wounded soldiers.The result of this continual expansion in eligibility and beds is that,at present, only 17% of patients in V.A. hospitals are being treatedfor service-connected disabilities; most of the others are admitted onthe basis of other criteria such as economic need (Cleland, 1979).

1. Unless otherwise indicated, historical information on veterans'medical care in this and other sections was drawn from two sources:Adkins, 1967. and Weber and Schmeckebier, 1934.

378

Despite the important influence of the V.A. and its employees,

the veterans' organizations, and supporters in Congress, veterans'medical services have also come under attack from a wide variety

of sources. Increase in access to these services for the non-dis-abled has been opposed by private medicine as unfairly competitive.The quality of care provided in veterans' institutions has beencontinuously challenged by journalists and scholars. Most recentlythere has been considerable debate within government over thepossibility of merger between V.A. and private medical care. Pro-ponents of this merger point to the fact that only in medical care

does the V.A. provide direct services rather than helping theveterans to purchase from the private market place, as it does in

education and housing. The possibility of national health insur-ance as well as criticisms of quality, cost, duplication ofservices, and difficulty of access have all fueled the controversyover the future of veterans' medical care. Nevertheless, the V.A.medical system has continued to grow and will certainly persist in

the foreseeable future (cf. Lindsay, 1975).

III. Influences on V.A. Health Care1) Political Interests

The fact that political influence of different groups has playedan important role in the development of the V.A. system is hardlysurprising, since it is a creature of the legislative process. Itis interesting, however, to examine the role of political influencein the expansion of facilities and benefits. The veterans' organi-zations (American Legion, Disabled American Veterans, Veterans ofForeign Wars, etc.) are the most intensely involved in influencingthe political process, and veterans in Congress play a strategicrole in the passage of legislation regarding the V.A.

The importance of political pressure from veterans is probablyas old as the existence of benefits. In the fifteenth century, forexample, when standing armies developed to serve feudal lords, dis-abled soldiers were cut off from community support, and they organi-zed to demand redress. This pressure led to the formulation of avariety of pension plans and domiciliary homes. These plans werelimited and mostly unsuccessful, but during the sixteenth andseventeenth centuries, the number of veterans' homes and assistanceplans increased in Europe, and these were adopted in part by theAmerican colonies.

Active organizing of veterans in the United States dates to theturn of this century. The United Spanish War Veterans was founded

in 1898; Veterans of Foreign Wars was established in 1913. Bothexerted pressure on Congress to expand benefits, and partly as aresult of this pressure, both pension and medical benefits weregreatly liberalized following World War I.

The effect of organized protest is also seen whenever efforts

are made to cut back on benefits. In 1933 Congress passed a bill,proposed by President Roosevelt in response to Depression conditions,which drastically reduced pensions and services for veterans. Aftermassive protest and despite a presidential veto, Congress reverseditself in 1934. A similar result occurred in 1965 when a new V.A.administrator ordered the closing of some outmoded and underutilizedhospitals and the building of new ones in other areas. Veterans'organizations,V.A. employees and Congressmen from the affecteddistricts opposed the plan, resulting in a review and modification.

More recently, a report by the National Academy of Sciences on"Health Care for American Veterans", commissioned by Congress,created a great furor by proposing the gradual integration of V.A.medical facilities with the private medical sector, suggesting thata separate system is unnecessary. Members of Congress interestedin veterans' affairs, many of whom are themselves veterans ofmilitary service, responded angrily by attacking the NAS study groupand initiating an audit of its books by the General AccountingOffice (Science, 1978).

According to an editorial in the New England Journal of Medicine(1978) commenting on the report's reception, "...the V.A. medicalcare system is a sacred cow. The whole subject is so loaded withpolitical emotion and vested interests that rational public discourseis hardly possible." An editor of Science responded similarly: "TheV.A., of course, has a unique clientele and a history of specialtreatment by Congress. There are roughly 28 million veterans who,with their families, constitute a potentially formidable votingbloc. Veterans' interests are championed by veterans' organizationswhich form a highly effective single interest lobby." In addition tothese groups, the many families supported by jobs in the V.A. hos-pitals also have an interest in their continuation. The editorialconcludes that the NAS study group had "triggered a powerful, protec-tive, conditioned reflex"(Science, 1978).

The organized pressure of interested groups combined with themilitary service history of many powerful members of Congress hasresulted in the continued expansion of services and benefits. Forinstance, recent legislation created counseling programs for Vietnam-era veterans, preventive health services for veterans with service-connected disabilities, and expanded medical services for dependents,

and increased outpatient dental care. When two fiscally conservativesenators challenged these expenditures in committee and succeeded incutting the amount of money allocated in the bill by one-third, theiraction was quickly reversed by the Congress. The combined effortsof veterans' groups, the V.A. staff, and veterans in Congress hasresulted in continual growth of such new programs and expansion ofeligibility for existing programs (Wehr, 1979a, 1979b, 1979c; Crosby,1979). Political influence has also played an important part in

the location of facilities; a number of cities are the sites of V.A.hospitals because they were the home towns of an American presidentor of an influential member of Congress (Sapolsky, 1977: 373-4).

Despite evidence of their continued impact on legislation,leaders of veterans' organizations worry about that they consider tobe a decline in their political influence. They point in particularto efforts by President Carter and the Office of Management andBudget to cut back on medical personnel, facilities, and benefits inorder to save money. The decreasing proportion of members of Congresswith military service histories and the fading of public support forveterans, especially after Vietnam, have made the V.A. increasinglyvulnerable to the actions of budget-conscious officials (Estill, 1979;Wehr, 1979d). According to the Twentieth Century Fund Task Force onPolicies toward Veterans, the strength of the veterans' organizationshas decreased steadily since the 1950's because of the lack of partici-pation of younger veterans. Nevertheless, "Theirs is virtually theonly point of view ever expressed before the congressional veteranscommittees.. .no countervailing political force has yet managed todispute effectively the view of the veterans' organizations". Thereport concludes that future Congressional response to organizedveterans' demands is "hard to predict" (Taussig, 1974: 57-9). Thedependence of medical services on political interests has up untilnow usually worked to the advantage of the V.A. system as a whole,but it may also ultimately lead to the curtailment of those services.

2) Military InterestsEducational, financial, and employment benefits have all been

used in the U.S., as elsewhere, to induce military enlistments.Historically, one major incentive for men to become soldiers has beenthe reward of plunder and some times even parts of the conqueredterritories. Other kinds of state-sponsored rewards also served asincentives to fight. The ancient Greeks freed helots who offereddistinguished service and also fed and pensioned disabled soldiers.An English law passed in 1592 to provide "for the Reliefe ofSouldiours" offered pensions to the disabled "to the end that theymay reap the fruit of their good deservings, and that others may beencouraged to perform the like endeavors." This latter intent wasreflected in legislation passed in the American colonies. New Hamp-shire in 1718 legislated medical care for disabled veterans "for thebetter encouragement of soldiers to adventure their persons againstthe enemy." George Washington, after initially opposing servicepensions for officers during the Revolutionary War, later changedhis mind when many officers deserted the ranks, and he wrote to theContinental Congress asking for pensions in order to be able to keepenough officers to win the war.

When the first peacetime conscription was established byCongress in 1940, the bill included a variety of benefits for vet-erans, intended in part to reduce opposition to the draft. Men werereluctant to give up their jobs during a time of high unemployment,and the promise of government assistance after their release fromservice was offered as an incentive to assure the success of con-scription. The G.I. Bill of 1944 was built upon these earlierprovisions (Olson, 1974).

3) Economic InterestsSome of the efforts made to encourage enlistment have also been

designed to assist the economy. For instance, in the nineteenthcentury, frontier lands were awarded to veterans, in part as a wayto promote the frontier regions of the country. During the Depress-ion, $3.5 million in adjusted benefits were awarded to World War Iveterans, and this was seen as a way of stimulating the weakenedeconomy. The G.I. Bill of 1944 was viewed not only as a reward tosoldiers for military service but also as a mechanism for supportingthe American educational system and the economy. According to Olson(1974), educational and financial benefits were enacted due to thefear that the reentry of veterans in great numbers into a shakyeconomy after the war would create massive unemployment and conse-quently dangerous political instability. The resulting advantageto individual veterans may be seen in the fact that their median in-come in 1977 was $4500 higher than that of non-veterans. The averageeducational attainment of veterans is higher than that of non-veterans, and at each educational level veterans have higher incomes(Cleland, 1979). Preference given to veterans in civil servicehiring has certainly contributed to this advantageous position.

The building of V.A. medical facilities constitutes an importantinvestment in a community and therefore may also be used as aneconomic tool. A recent decision to build a new V.A. hospital inCamden, N. J. despite the existence of facilities in nearby Phila-delphia, resulted from persistent political pressure on PresidentCarter, who reversed his opposition to the plan. Camden's mayordescribed the project as "the cornerstone of a rebuilding programintended to restore the city's economic viability." The hospitalwas expected to generate 1000 jobs directly and many more indirectlybecause of the growth of doctors' offices, restaurants, bank branches,and other business (New York Times, Feb. 22, 1978).

The V.A. system has also contributed to the economic well-beingof professional interests. Medical schools, for instance, have foundV.A. hospitals to be a useful source of "teaching material," researchfunds, and additional teaching staff (Sapolsky, 1977). In 1978, theV.A. had 2000 arrangements with schools teaching health professionals,and more than 97,000 students received training in V.A. facilities(Cleland, 1979). The Camden V.A. Hospital, for instance, was plannedin conjunction with the expansion of a private medical center to in-clude training of medical students.

4) Organized Medical InterestsDespite these economic and teaching advantages, one would

expect organized medical interests to oppose the expansion of V.A.

services. The AMA, for instance, has waged a battle against state-funded or administered medical care for decades (Burrow, 1963;Marmor, 1970; Stevens, 1971). Yet the V.A. has received consider-

able assistance and support from the AMA and from prominent medical

educators. Since 1924, advisory groups of physicians from a broad

range of specialty areas have been formed to assist the veterans'medical system. The first of these, the Medical Council, was

chaired by Dr. Ray Lyman Wilbur, at that time President of Stanford

University and also President of the AMA. The Secretary was Dr.

Malcolm MacEachern, Associate Director of the American College of

Surgeons, and the other officers were medical school professors.

The Council endorsed the establishment of relations between V.A.

hospitals and medical schools and the carrying out of medical re-search by the V.A.

Formal affiliation with medical schools was authorized in 1946,

and it has been seen as a major factor in upgrading the quality ofV.A. medical care (National Academy of Sciences, 1977: 253). This

relationship has been applauded both by the American Association of

Medical Colleges and the editors of the Journal of Medical Education(JME, 1977). Adkins concluded that the "V.A. has the cooperation of

organized medicine and an excellent reputation" (1967: 220).

The alliance with medical schools, however, has also been

strongly criticized. It has resulted, according to some scholars,in the abandonment of the needs of the V.A.'s primary clientele--the chronically disabled, both physically and mentally--for theattractions of acute tertiary care and teaching (Lipsky, et al, 1976;

Sapolsky, 1977).

Despite this history of cooperation, organized medical interestsdid oppose some facets of V.A. expansion, in particular, the in-

clusion of non-service connected veterans. The provision of general

medical care for these patients more clearly intruded into the do-main of private medicine. During the post-World War II period of

V.A. reorganization, the AMA House of Delegates passed a resolution

expressing its "long-established opposition to any attempt at thesocialization of medicine in America by extending medical benefits

under the Veterans Administration to encompass disabilities that are

not service-connected or to general medical care of the dependents

of veterans" (Starr, 1973: 75). Starr concludes that this ongoingopposition significantly slowed the development of V.A. health

services and that the more recent extension of benefits (outpatient

care for non-service connected veterans and services for some depend-

ents) may be attributed to a decline in AMA power.

5) Ideological ComponentThe history of social welfare is permeated by repeated attempts

to separate the "deserving" from the "undeserving" and to providebenefits only for the former. Legislators as well as private agencieshave sought to make assistance available only to those whom they havedetermined not to be personally at fault for their misfortune, par-ticularly children, the elderly, the disabled, and widows. Able-bodied men have rarely received aid because, except in cases ofsevere national depression or disruption, they have been assumed tobe responsible for their own suffering. This idea of individualresponsibility is a strong ideological component of capitalism anda persistent theme in public opinion and in social policy (Rimlinger,1971; Feagin, 1975; Galper, 1975). Its consequence is the limitationof assistance only to those who demonstrate exceptional circumstancesor merit.

The veteran, and especially the disabled veteran, is an excellentexample of this principle. He (and in 98% of cases the veteran is amale) has been treated not only as the victim of exceptional circum-stances but is doubly deserving for having served the country inbattle. He has therefore "earned" the right to a variety of benefits,including education, employment advantages, and medical care.

Robinson Adkins, a V.A. official and the author of a history ofveterans' medical care, wrote, "The American people, acting throughCongress, have supported the principle that a man who devotes part ofhis life--usually his young manhood--to defend his country, should beoffered advantages over those who do not" (1967: 4). The principleof rewarding those who have served in the military is a very old one.In ancient Rome, muncipal offices were often awarded to veterans andtheir descendants. Throughout the Middle Ages, various forms of cashrelief and institutional care were provided for veterans. During thenineteenth century in the United States, veterans received free landas well as pension benefits. In 1917, when Secretary of the TreasuryMcAdoo transmitted to President Wilson legislation expanding veterans'benefits, he wrote, "Every man should know that the moment he is en-listed in the military service of the Government these definite guar-antees and assurances are given to him, not as charity but as part ofhis deserved compensation for the extra hazardous occupation intowhich the Government has forced him" (Adkins, 1967: 94). Most re-cently, in response to proposals that the V.A. medical system bephased out, an economist commented that this would deprive many needyveterans--the elderly, poor, and chronically ill--of access to medicalcare (Ginzberg, 1978). The underlying assumption appears to be thatthese categories of people are more entitled to such care if they areveterans.

The provision of services to veterans is thus based on the notionthat they have deserved it. The distinction according to merit isalso found even within the veteran population. The most basic differ-

entiation among veterans is between those with service-connected

disabilities and those who were not disabled as a result of militaryservice. This distinction has governed pension and compensationbenefits since these were first voted in the U.S. in 1776 for dis-abled Revolutionary War soldiers. Although eligibility for medicalcare has been constantly redefined to include more veterans and

more kinds of services, service-connected disability has remained

the principle guarantee of care. Since 1924 financial need has alsobeen considered a basis for hospital care if beds are available.Outpatient care, available originally only for service-connecteddisabilities, was extended in 1973 to veterans without disabilitiesif they are eligible for hospitalization and if such care is re-lated to or would prevent hospitalization. Disabled veterans aresubject to the same limitations if they seek outpatient treatment

for a condition not related to their disability. Veterans withoutservice-connected disabilities may also be hospitalized if they are

65 or older or if they are Medal of Honor winners. An honorabledischarge and at least one day of active duty are prerequisites forany health care (National Academy of Sciences, 1977).

The eligibility criteria which must be met by applicants forV.A. medical care are increasingly complex. Each time that Congressenacts new medical benefits, it sets restrictions on categories ofveterans who are eligible for them, and a priority ranking establish-ing who should be admitted first in case of insufficient facilities.

For instance, dental benefits were extended in 1979 to veterans ofthe two World Wars and Korea, the totally disabled, and Vietnamveterans who had been prisoners of war for more than six months. Atthe same time, World War I veterans were accorded top priority rank-ing for access to outpatient medical services (Wehr, 1979c, 1979d).

Each year, approximately 20% of all applications for medicalservices are rejected as ineligible or not in need of care (Cleland,1977, 1978, 1979). Only 10-13% of veterans use V.A. health services,suggesting that the large majority never apply. The priority systemwas created by Congress specifically to limit access to V.A. healthcare, and it certainly is one important factor in reducing utilization.Many veterans do not use V.A. facilities either because they are in-

eligible or because they mistakenly think they are. In a recent

survey of rural veterans, the failure to use V.A. medical care wasoften explained as resulting from uncertainty about eligibility. The

essential point is that eligibility, not need, governs access to V.A.system. This principle is characteristic of other health and welfareservices.

IV. Impact on Distribution

The limitation of governmentally-run services to "deserving"groups, the importance of political and economic forces in determining

where facilities will be built, and the use of health services to pro-mote military aims, all have the effect of exacerbating inequities inthe U.S. medical care system. In particular, rural residents and

385

women are at a disadvantage, the former because of inaccessibilityof services, the latter because of eligibility requirements. When-ever medical resources are allocated by the state for purposes otherthan the alleviation of suffering and on bases other than need, theresult is inequality in the availability of services to potentialpatients.

The distribution of 172 hospitals in a country the size of theUnited States inevitably leads to difficulties of access for manyeligible veterans. Since distance is generally related to the useof medical services (Shannon et al, 1969), it is not surprising thatrural veterans are much less likely to take advantage of their medicaleligibility. A study of the use of services by veterans living onCape Cod, for example, showed that the hour and half to three hourstraveling time to a V.A. hospital inhibited its utilization. A re-view of outpatient records at the Providence V.A. Hospital, whichserves Cape Cod as part of its region, revealed that only 1.1% ofvisits between March 1 and June 30, 1976 were by veterans from theCape. Yet the veteran population on Cape Cod constitutes 8% of theveterans in the Providence region. A survey of veterans on Cape Codrevealed an almost total lack of use of V.A. medical facilities(Wessen et al, 1976). In a recent survey of 200 men in three ruralcounties in Central Pennsylvania, a similar failure to use any V.A.services was found.

Medical services for veterans, as with social and health servicesgenerally, begin and expand or contract in response to the organizedpolitical activity of client groups, legislators, the military, andthose provider groups who might either benefit or suffer from greaterinvolvement of the state. Consequently, services are often mal-distributed or inappropriate. The location of hospitals has beendecided on the basis of prestige needs of powerful leaders or lobby-ing abilities of local communities and their representatives ratherthan on an assessment of need. (The V.A. has so far been exemptfrom the certificate of need regulations governing private medicalfacilities).

V. Conclusion

Navarro writes that the American health care system reflects theclass structure of U.S. society in its organization and in thedecision-making process. Veterans' benefits, medical care being amajor portion, may be analyzed similarly. They are neither ananomaly nor an anachronism. They directly respond to the economic,military and political priorities of powerful groups in the society.The fact that V.A. health services are federally financed and or-ganized, not unlike the health systems of Eastern Europe, hardlymeans that socialism is rampant in the American government. Itsuggests rather that military goals are central to the society and,

that, as a result, veterans are a powerful lobby and have the supportof much of the population in their efforts to expand "well-earned"benefits. The V.A. system dramatically supports the dominant Americanvalue that services are a privilege to be earned and not a right ofcitizenship. This is certainly not a socialist approach. In addi-tion, the care of aging, poor, and chronically disabled soldiers isgenerally uninteresting and unprofitable for the acute-care orientedpractitioners who dominate private medicine, and they have not soughtto take on this responsibility.

A national health system modeled on the V.A. may reflect thesame principles and produce the same results. This would particularlybe the case if national health care coexists with the private system,the former covering only special categories of people and those whoare uninteresting to or cannot afford private medical care. Compe-tition between the two systems for money and personnel has createdsome disadvantages for the V.A., since the resources of privatemedicine are so much greater (Starr, 1973). Continued coexistenceof the two systems will perpetuate the weaknesses of the publicservices, as has already been seen in cities where public and privatehospitals exist side by side (Kotelchuck, 1976).

The V.A. medical system has often benefited from the interestsdiscussed here, but it is also vulnerable because of them. Unfavor-able public reactions to the Vietnam War have diminished the "deserv-ing" aura around its veterans, and thus weakened popular commitment toveterans' services. The reduction in numbers of veterans in Congressand the "deep generational divisions" between veterans of Vietnam andof earlier wars over the form that benefits should take (Wehr, 1979a)have resulted in attenuated political influence. In addition, budget-ary concerns have led members of Congress to challenge the expenditureof funds for veterans as being too costly (Wehr, 1979b).

Certainly the V.A. medical system has provided much-needed carefor millions of people. However, a study of the V.A. providesfurther evidence that societal resources are not distributed in res-ponse to universalistic principles of medical necessity (nor ofeconomic efficiency). The predominance of other goals may presentproblems for many veterans (e.g. those in rural areas) as well as fornon-veterans, who are excluded from this potentially important sourceof medical care.

387

References

Adkins, Robinson1967 Medical Care of Veterans. Committee on Veterans' Affairs:

U.S. Congress.

Burrow, James1963 AMA: Voice of American Medicine. Baltimore: Johns

Hopkins Press.

Chase, John1977 "The V.A. Health Care Delivery System and National Health

Insurance", Alabama Journal of Medical Science 14: 369-373.

Cleland, Max1977 Annual Report 1976. Washington, D. C.: Administrator of

Veterans Affairs.

1978 Annual Report 1977. Washington, D.C.: Administrator ofVeterans Affairs.

1979 Annual Report 1978. Washington, D.C.: Administrator ofVeterans Affairs.

Crosby, Imani1979 "Spending Increased for Veterans' Benefits." Congressional

Quarterly Weekly Bulletin (Jan 7): 134.

Estill, Robert1979 "Veterans Lose Clout in D.C.." Bloomsburg, Pa.: The

Morning Press (November 22): 15.

Feagin, Joe1975 Subordinating the Poor; Welfare and American Beliefs.

Englewood Cliffs, New Jersey: Prentice-Hall.

Field, Mark1957 Doctor and Patient in Soviet Russia. Cambridge: Harvard

University Press.

Galper, Jeffrey1975 Politics of Social Services. Englewood Cliffs, New Jersey:

Prentice-Hall.

Ginzberg, Eli1978 "The NAS Report on the V.A.: How Not to Offer Congress

Advice on Health Policy." New England Journal of Medicine

298 (March 16): 11.

Journal of Medical Education1977 "The V.A.-Medical School Relationship." 52: 1.

Kotelchuck, David1976 Prognosis Negative; Crisis in the Health Care System.

New York: Vintage.

Krause, Elliot1977 Power and Illness; The Political Sociology of Health and

Medical Care. New York: Elsevier.

Lasker, Judith1977 "The Role of Health Services in Colonial Rule." Culture,

Medicine, and Psychiatry 1: 277-297.

Lindsay, Cotton

1975 Veterans Administration Hospitals; An Economic Analysisof Government Enterprise. Washington, D. C.: American

Enterprise Institute for Economic Research.

Lipsky, Michael, Lawrence McCray, Jeffrey Prottas, and Harvey Sapolsky

1976 "The Future of the Veterans' Health Care System." Journal

of Health, Politics, Policy, and Law 1 (Fall): 285-294.

Marmor, Theodore1970 The Politics of Medicare. Chicago: Aldine.

National Academy of Sciences

1977 Study of Health Care of American Veterans. Washington, D. C.

Navarro, Vicente1976 Medicine under Capitalism. New York: Prodist

1977a "Social Class, Political Power and the State and theirImplications in Medicine", International Journal of Health

Services 7: 255-292.

1977b Social Security and Medicine in the USSR. Lexington, Hass:

Lexington Books.

New England Journal of Medicine

1978 "The Future of the Veterans Administration Hospital System:

Two Points of View," 298 (March 16): 11.

New York Times1978 February 22: 51. (New Jersey).

Olson, Keith1974 The G.I. Bill, The Veterans, and the Colleges. Lexington:

University Press of Kentucky.

Piven, Frances Fox, and Richard Cloward

1971 Regulating the Poor: The Functions of Public Welfare.New York: Pantheon.

389Rimlinger, Gaston1971 Welfare Policy and Industrialization in Europe, America,

and Russia. New York: John Wiley.

Sapolsky, Harvey1977 "America's Socialized Medicine! The Allocation of Resources

Within the Veterans' Health Care System." PublicPolicy 24 (Summer): 3.

Science1978 Editorial, Vol. 199 (March 3): 952-956.

Shannon, Gary et al.1969 "The Concept of Distance as a Factor in Accessibility and

Utilization of Health Care." Medical Care Review 26(February): 143-161.

Starr, Paul1973 The Discarded Army; Veterans after Vietnam. New York:

Charterhouse.

Stevens, Rosemary1971 American Medicine and the Public Interest. New Haven:

Yale U. Press.

Taussig, Michael1974 Those Who Served. Twentieth Century Fund Task Force on

Policies toward Veterans. New York: Twentieth Century Fund.

Waitzkin, Howard1978 "A Marxist View of Medical Care." Science for the People 10

(Nov/Dec): 31-42.

Weber, Gustavius A. and Laurence Schmeckebier1934 The Veterans Administration; Its History, Activities and

Organization. Service Monographs of the U.S. GovernmentNo. 66. Washington, D. C.: Brookings.

Wehr, Elizabeth1979a "Freshman Senators Stall Veterans' Health Bill." Congress-

ional Quarterly Weekly Bulletin. February 17: 297-8.

1979b "Spending Levels Chopped in Veterans' Health Bill."Congressional Quarterly Weekly Bulletin. March 17: 477-8.

1979c "Psychological Aid for Vietnam Vets Approved." Congress-sional Quarterly Weekly Bulletin. may 26: 1015-1017.

1979d "Carter Efforts to Cut V.A. Hospital Staffs Opposed."Congressional Quarterly Weekly Bulletin. June 23: 1251-2.

Wessen, Albert, Judith Lasker and Richard Fortinsky

1976 "Report to Veterans Administration on Health Needs and

Activities of Cape Cod Veterans." Mi ne